Hyperemesis gravidarum (HG)

This leaflet aims to give you information about hyperemesis gravidarum (HG), what it is and how it can be treated, to help you understand the condition.

It includes information on:

• where to seek help
• the signs and symptoms
• aim of treatment
• how the condition is managed

Medication

Bring all of your medicines (including inhalers, injections, creams, eye drops or patches), and a current repeat prescription from your GP.

Please tell the staff about all of the medicines you use. If you wish to take your medication yourself (self-medicate) during your stay please discuss this with your nurse. Pharmacists visit the wards regularly and can help with any medicine queries.

What is hyperemesis gravidarum?

Nausea and vomiting in early pregnancy is very common and affects most women to some degree. It usually settles by 16 to 20 weeks, although it can last longer in some women and does not have an adverse effect on the mother or baby. However, if the nausea and vomiting is severe and persistent to the extent that you are unable to keep food or liquid down, you have lost more than 5% of your pre-pregnancy weight, and are dehydrated and have an imbalance of the electrolytes (salts) in your blood, this is called ‘hyperemesis gravidarum, or 'HG'.

Hyperemesis gravidarum can affect up to 3.06% of all pregnancies. It generally clears after the first 16 to 18 weeks of pregnancy, but for some women it can continue throughout their pregnancy. It affects just a small percentage of pregnant women but there is a high risk of it recurring in future pregnancies.

Where can I seek help?

(Please see the contact information at the foot of this leaflet.)

Clinic 24 – early pregnancy and emergency gynaecology unit

If you are suffering with severe nausea and vomiting in pregnancy in your first trimester (up to 16 weeks gestation) please contact Clinic 24. You can self-refer by contacting us on the telephone numbers provided below or you can be referred by your GP or midwife.

You will be assessed over the phone by a nurse or health care assistant. We aim to treat you as a day case in Clinic 24 where you will be assessed on arrival and a plan of care will be made. This might include giving you intravenous fluids and anti-sickness medication to help reduce nausea and vomiting. If you are still unwell following this management you may be admitted to an inpatient bed on Daphne Ward for further care. If your symptoms persist after 16 weeks gestation, your care may be referred to our maternity medicine department (Clinic 22) for further follow-up and ongoing management.

Clinic 22 – maternity medicine department

When your gestation is beyond 16 weeks, the team in Clinic 24 will refer you for ongoing management with Clinic 22.

What are the causes?

The cause is unknown; however, it is believed to be due to hormonal changes in pregnancy.

What are the signs and symptoms?

• inability to keep down food or water
• unintentional weight loss
• dizziness and fainting
• prolonged and severe nausea and vomiting
• passing a lower volume of or more concentrated urine
• inability to swallow saliva
• feeling dry

How will it make me feel?

Hyperemesis gravidarum can be difficult to cope with. It can affect you physically and can affect your mood, your work and your home situation. Friends and family support can help. If you are finding that you feel persistently down, please speak to your GP, nurse or midwife. You may also find some support from Pregnancy sickness support (opens in a new tab), a charity dedicated to supporting women with HG.

What does the assessment involve?

We will ask you about your medical and obstetric history. This will include:

• any medications you are currently taking
• history of nausea and vomiting in pregnancy
• previous or current mental health concerns
• any history of blood clots in your legs or lungs

We will assess your symptoms using a scoring system called a PUQE score at each visit. This will assess:

• how long you have had the symptoms
• what you are managing to eat or drink
• any weight loss
• whether you have any abdominal pain or urinary symptoms
• whether you have any vaginal bleeding
• a set of observations, including temperature, pulse, respiratory rate, blood pressure and oxygen saturations
• an abdominal examination (if you have pain)
• height and weight
• urine test to check for any signs of infection
• blood tests: to review your electrolyte balance and a 'finger prick' test to assess your glucose levels

What is the aim of treatment for hyperemesis gravidarum?

Treatment aims to:

• rehydrate
• break the cycle of vomiting that leads to dehydration
• ensure there are no other causes for the nausea and vomiting

How will I be treated?

Day case care

If you meet certain criteria when you are assessed you will be offered day case management. This involves:

• observations taken every two hours
• fluid replacement to correct dehydration; this will be given through a drip in your arm
• anti-sickness medication; this can be given through the drip in your arm, as an injection, or as a tablet (you may need a combination of medications to control your symptoms)

We will allow you home once you are able to tolerate some oral diet and fluids.

Inpatient care

If the above treatment is not as effective as both we and you would wish and if you meet certain criteria you will be offered inpatient management. This involves the above treatments plus the following:

• observations taken every one to two hours
• daily weight
• daily blood tests
• you may be given H2 receptor antagonists or proton pump inhibitor medication (antacids), which can be given through your drip or as a tablet
• you will be given anti-embolic stockings to wear and an injection of an anticoagulant to reduce the risk of blood clots
• you may be referred to the dietitian for further support in managing your HG
• you may be offered an early ultrasound scan to check how many weeks pregnant you are, possible multiple pregnancies, and other possible factors for HG. This may not happen whilst you are still admitted but it will be organised by the Daphne Ward and Clinic 24 team
• consideration of a PICC line. A PICC line is a long, hollow tube made of silicon rubber which is placed into one of the large veins in the arm. One end of the line comes out from the arm and can be used for injections and the other end is positioned inside a large vein, usually near to the heart. This is a method of giving intravenous fluids directly into your circulation and this can stay in for up to six months. It negates the need to have a new cannula (drip) placed into your arm on every admission. If you have a PICC line sited you will require weekly dressings whilst it is in place. This can be done on any of your hospital visits or by your practice nurse.
• steroid treatment – if you are given steroid treatment, you will be monitored for gestational diabetes
• vitamins either orally or through your drip

If you are unable to tolerate anything orally for five days, you will be referred to the parenteral nutrition (PN) team for possible feeding by the PICC line. This is a different way of providing all the nutrients your body needs whilst you cannot eat. It is introduced directly into the bloodstream, bypassing the digestive system. If you have PN feeding you will have a finger prick performed daily.

We will allow you home once your urine tests are normal and you are able to tolerate some diet and fluids.

Benefits

The aim of the treatment is to make you feel better physically and emotionally by allowing you control over your nausea and vomiting in order to continue with your day to day life.

Risks

Should you require a drip or PICC there is a risk of infection and/or bruising. These risks are minimised by observance of appropriate techniques when a cannula or PICC line are inserted and during weekly dressing changes.

Women with HG are at an increased risk of blood clots as the blood can be thicker. We therefore aim to minimise this risk by giving you anti-thromboembolic injections and asking you to wear anti-embolic stockings. If you have a history of blood clots, please let your healthcare provider know.

Alternatives

The alternative to this treatment is to decline treatment. The consequences of this will be discussed with you.

Advice for discharge

On discharge you will be given oral medication to help control the nausea and vomiting. We recommend that you take any medication you are given regularly and not as you need it as this will help it to be more effective. You will need to see your GP for repeat prescriptions. If your symptoms persist or worsen, please contact Clinic 24.

Practical tips to help at home:

• Try eating little and often throughout the day.
• Take your time with meals: try to relax and eat slowly.
• Avoid fizzy or caffeinated drinks.
• Drink plenty of fluids.
• Avoid triggers such as rich, spicy or fatty food.
• Cold food options may be easier to manage.
• Get some fresh air and exercise daily.
• Avoid wearing tight fitting clothes.

Contacts and further information

If you have any further questions or anxieties at any time, please feel free to ask a member of staff.

Clinic 24 (early pregnancy and emergency gynaecology unit)

01223 217636

Monday to Friday – 08:00 (8am) to 20:00 (8pm)
Weekends – 08:30 (8:30am) to 14:00 (2pm)
Bank holidays – closed

Daphne Ward (inpatient gynaecology ward)

01223 257206

At all other times

You can also attend the emergency department (ED) at any time if you are concerned and clinic 24 is closed.

Pregnancy sickness support (opens in a new tab)

0800 055 4361

Monday to Friday – 09:00 (9am) to 17:00 (5pm)

References and sources of evidence

• McCarthy FP, Lutomski JE and Greene RA, 2014. Hyperemesis gravidarum: current perspectives. International Journal of Women’s Health. 2014; 6: 719–725
• Royal College of Obstetricians and Gynaecologists, 2016. GTG 69: The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum. (opens in a new tab)

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high-tech equipment and/or specialist one-to-one care is required.